Provider Demographics
NPI:1487622320
Name:SUTHERLAND, CLINTON HALE (MD)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:HALE
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:391 FALLS DR NW
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-8093
Practice Address - Country:US
Practice Address - Phone:276-628-4406
Practice Address - Fax:276-628-4906
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049088207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006076661Medicaid
VA006076661Medicaid
VA110004839Medicare PIN
VAVAA100996Medicare PIN
VAF56284Medicare UPIN